44.10 Nasal Oxygen Supplementation in Asymptomatic Thoracic Surgery Patients

Posted on January 18, 2018

M. H. Chowdhury1,2, R. G. Vaghjiani2, P. S. Adusumilli2  1Marshall University Joan C. Edwards School Of Medicine,Huntington, WV, USA 2Memorial Sloan-Kettering Cancer Center,Thoracic Service, Department Of Surgery,New York, NY, USA

Introduction: Supplemental nasal oxygen is often administered to patients with asymptomatic desaturations based on pulse oximetry measurements. To date, there are no established parameters which guide the use of oxygen in the post-operative patient. As a first step, we investigated a) the incidence of oxygen supplementation in post-operative patients, b) the patterns of supplementation, c) the rate of home-use oxygen prescribed at discharge, and d) the associated post-operative outcomes of these patients. 

Methods:  A single institution, retrospective chart review was conducted on all consecutive patients who underwent lung resection from January to December 2016. Clinical outcomes including length of stay, complications, and readmission rates were collected from the prospectively maintained MSK thoracic surgery database and the electronic medical record.

Results: In total 574 patients underwent lung resection, 51% were male and had a mean age of 68.1 years. Of the 49 patients (Table) who were discharged with home-use oxygen, 34 (70%) had received more than 24hrs of continuous oxygen supplementation during their post-operative inpatient admission.   

Conclusion: Nearly 1 in 10 patients are discharged with oxygen after lung resection. The use of supplemental oxygen is not without cost, and the specific burden on patients may be significant. This study provides an initial insight into the utilization of supplemental oxygen following lung resection and may serve as the basis for further studies investigating the need for oxygen in patients with asymptomatic desaturation. 

 

44.11 Atrial Fibrillation After Anatomic Lung Resection: Amiodarone Prophylaxis and Risk Stratification

Posted on January 18, 2018

E. D. Porter2, K. A. Fay1, T. M. Millington1, D. J. Finley1, J. D. Phillips1  1Dartmouth-Hitchcock Medical Center,Department Of Thoracic Surgery,Lebanon, NH, USA 2Dartmouth-Hitchcock Medical Center,Department Of General Surgery,Lebanon, NH, USA

Introduction: Post-operative atrial fibrillation (POAF) is a known complication after anatomic lung resection. Currently, no formal recommendations exist for its prophylaxis nor its management strategies. In this study, we identifiy trends in outcomes and preoperative risk factors at a single center that implemented a protocol of amiodarone prophylaxis after anatomic lung resection.

Methods: Cohort study at a single tertiary referral center. All patients who underwent anatomic lung resection from January 1, 2015 to April 26, 2017 were selected. Those ≥ 65 years of age, or at the discretion of the Attending Surgeon, were assigned to receive a post-operative amiodarone bolus 300mg IV over 1hour followed by 400mg PO TID x 3 days. Patient charts were reviewed for demographics, co-morbidities, and complications.

Results: A total of 227 patients underwent anatomic pulmonary resection and 27 (13.5%) experienced POAF. One hundred and seventeen patients (51.5%) were ≥ 65 years old. Of those 117 patients, 95 (81.2%) received amiodarone prophylaxis post-operatively and 18.8% experienced POAF. Those who developed POAF were more likely to be older (71.1 vs 65.0, p=0.001), have a history of Afib (p=0.019), have undergone a lower lobe lung resection (p=0.002), and/or had an open procedure (p=0.037). POAF significantly increased the post-operative length of stay (6.8 vs 4.4 days, p=0.004).

Conclusion: Post-operative atrial fibrillation continues to be a challenging problem after anatomic lung resection. Further investigation to establish optimal prophylactic medications and to identify high-risk patients for POAF prevention are needed. Our data suggest that POAF is more common in older patients, those with a history of a-fib, patients undergoing a lower lobe resection, and those having an open procedure. Targeted prophylaxis to these groups may be warranted.

44.09 Perioperative Renal Replacement Therapy Predicts Mortality in Mechanical Circulatory Support

Posted on January 18, 2018

J. M. Tatum1, M. L. Barr1, B. Abt1, M. E. Bowdish1  1Keck School Of Medicine Of The University Of Southern California,Division Of Cardiothoracic Surgery,Los Angeles, CA, USA

Introduction:
Perioperative renal replacement therapy (RRT) is frequently required in patients undergoing implantation of a mechanical circulator support device. It is unknown how perioperative renal replacement therapy effects survival.

Methods:
Retrospective single center review of all patients receiving mechanical circulatory support devices between 2010 and 2015 with follow up until 2016. Patients on chronic preoperative hemodialysis were excluded. Patients were divided into two groups for analysis, those who received perioperative RRT and those who did not.

Results:
A total of 116 patients were included in the study, 46 required RRT. Of these 46 patients, 11 required pre-operative RRT, 45 required post-operative RRT and 10 required both. Mean age was 60 years, 77% were male and these characteristics were not significantly different between groups. Mean duration of RRT was 7 ± 3 days. Follow up survival data is complete for all patients. Mean follow up time was 721 days. Kaplan-Meier analyses were performed showing that the need for any peri-operative RRT significantly decreased post-operative survival, HR 2.4 (95% CI: 1.4-2.9), p = 0.001. The need for only post-operative RRT also significantly decreased survival, HR 2.2 (95% CI: 1.4-3.4), p = 0.001.

Conclusion:

Mechanical circulatory support devices should be used with caution in patients who require RRT in the pre-operative period and in patients where there is a strong clinical suspicion that post-operative RRT will be required. The use of mechanical circulator support devices as a destination therapy in these patients is cautioned against.

44.07 Early Outcomes of Adult Patients Who Undergo Proximal Aortic Surgery with del Nido Cardioplegia

Posted on January 18, 2018

J. L. Liao1,2, M. D. Price2, S. Y. Green2, H. Amarasekara2, J. S. Coselli2, S. A. LeMaire2, O. Preventza2  1Indiana University School Of Medicine,Indianapolis, IN, USA 2Baylor College Of Medicine,Cardiothoracic Surgery,Houston, TX, USA

Introduction: Currently, many cardioplegic solutions exist for myocardial protection during open cardiac operations. del Nido cardioplegia differs from others in that it includes lidocaine, which limits sodium influx in order to produce a depolarizing cardiac arrest. It also generally necessitates fewer doses, sometimes only one, during an operation. Although del Nido is commonly used in pediatric patients, its efficacy in adults is less well established. Recent literature has described promising results in adults undergoing coronary artery bypass. However, the outcomes of using del Nido in proximal aortic surgery—which generally involve substantially longer periods of cardiac ischemia—are not well described. The aim of our study was to characterize early outcomes of patients who underwent proximal aortic surgery with del Nido cardioplegia.

Methods: We retrospectively reviewed data from 59 consecutive patients (mean age 61±15 y; male [n=37, 63%]) who underwent proximal aortic surgery and received del Nido cardioplegia between July 2016 and July 2017. In most cases, an initial dose of approximately 1000 mL was administered, followed by 300-400 mL every 20-30 min. 34 (58%) patients had an aneurysm without dissection, 21 (36%) had DeBakey Type I dissection, and 4 (7%) had Type II dissection. 6 (10%) patients had heritable thoracic aortic disease. 14 (24%) had total arch replacement and 35 (59%) had hemiarch replacement. Concomitant procedures included coronary artery bypass (n=4, 7%) and repair/replacement of the aortic valve (n=33, 56%), aortic root (n=22, 37%), mitral valve (n=1, 2%), and tricuspid valve (n=2, 3%). Hypothermic circulatory arrest (median duration 37 min, 22-55 IQR) and antegrade cerebral perfusion (median duration 34 min, 22-55 IQR) were used in 51 (86%) patients. The median cardiopulmonary bypass and cardiac ischemic times were 140 min (118-176 IQR) and 110 min (87-129 IQR), respectively.

Results: There were 3 (5%) operative deaths. Only 3 (5%) patients required intraoperative defibrillation, and 2 (3%) required intra-aortic balloon pump. 41 (70%) patients required inotropic support immediately postoperatively, but only 9 (15%) required it beyond 24 hours. Of these 9, 3 died—2 due to multiple organ failure and 1 due to stroke—5 recovered completely with no reduction in left ventricular (LV) function, and 1 recovered with mild reduction in LV function. No patients developed myocardial infarction. Stroke occurred in 2 (3%) patients (both persistent). Other postoperative complications included renal dysfunction (n=8, 14%) and renal failure requiring hemodialysis (transient [n=4, 7%]; persistent [n=2, 3%]).

Conclusions: As the use of del Nido cardioplegia becomes more common in adult cardiac cases, it becomes increasingly important to obtain outcomes data. Based on our study, the use of del Nido appears to provide satisfactory myocardial protection in complex proximal aortic cases that tend towards long ischemic times.

 

44.08 The Effect of Alcohol Abuse on Peri-operative Outcomes among Cardiac Surgery Patients

Posted on January 18, 2018

M. M. Jamil2, A. Akujuo1, M. Tafen Wandji1, J. Ortiz2  1Albany Medical College,Albany, NY, USA 2University Of Toledo Medical Center,Surgical Education,Toledo, OH, USA

Introduction:  

Alcohol abuse has been associated with various cardiac dysfunctions. The effect of alcohol abuse on perioperative mortality and complications after cardiac surgery is unclear. 

Methods:

We analyzed the National Inpatient Sample database for patients over 30 years having CABG and/or other cardiac (OC) procedures (valvuloplasty, septal defect repair etc) between 2008 and 2012. Patients were stratified based on presence or absence of alcohol abuse (AA). Chi square/Kruskall Wallis test were used to compare demographics and comorbidity. The effect of alcohol abuse on mortality was estimated as Odd’s ratio and 95% confidence interval, using logistic regression with adjustment for demographics and comorbidities. Length of stay, charges, discharge disposition, and complications were also compared.

Results:

Between 2008 and 2012, a total of 1,482,018 patients (1,129,236 CABG and 550,709 OC) were reviewed. The incidence of AA was 2.7%. Patients in the 30-50 years category had the highest incidence of AA (4.31%). Males had a higher incidence of AA (3.6%) compared to females (0.8%). Blacks had the highest incidence of AA (3.4%) and Asian/Pacific Islanders had the lowest (1.3%). Patients with non-elective admission had a higher incidence (3.5 vs. 2.0%) of AA compared to elective ones. Patients with higher Elixhauser comorbidity index had a higher incidence of AA (2.4% in the first and 3.4% in the fourth quartile of ECI). Mortality among patients with AA was 1.8% compared to 2.9% among ones without AA (p=0.000). Unadjusted Odd’s ratio for mortality for AA was 0.61 (95% CI: 0.52-0.72) and persisted after adjustment for age, sex, elective/ non-elective status and Elixhauser comorbidity index. The incidence of atrial fibrillation was lower among patients with AA (28.73% vs. 32.63%, p=0.000). Postoperative respiratory failure and hepatic encephalopathy were higher among patients with AA (10.63 vs. 6.73%, p=0.000 and 0.22 vs. 0.07%, p=0.000 respectively). Length of stay and charges were slightly higher among patients with AA (median 9 vs. 8 days and USD 168,512 vs. 156,928 respectively). 

Conclusion:

Our results appear counterintuitive to traditional views regarding alcohol abuse among cardiac surgery patients. Although alcohol has been associated with cardiac dysfunction, there may be a mechanism for the apparent protective effect in the immediate postoperative period, which merits further investigation. 

 

 

 

44.04 Lower Hematocrit Levels are Associated with Neurocognitive Decline after Cardiac Surgery

Posted on January 18, 2018

A. Y. Gorvitovskaia1, L. A. Scrimgeour1, B. A. Potz1, C. D. Gordon1, N. Sellke1, A. Kuczmarski1, J. G. Fingleton1, A. Ehsan1, N. R. Sodha1, F. W. Sellke1  1Brown University School Of Medicine,Division Of Cardiothoracic Surgery,Providence, RI, USA

Introduction:
Cardiopulmonary bypass is associated with post-operative neurocognitive dysfunction; however, risk factors have not been clearly identified. Therefore, we hypothesize that lower hematocrit (Hct) levels may be correlated with post-operative neurocognitive dysfunction. 

Methods:
Thirty patients underwent screening for neurocognitive dysfunction pre-operatively and at post-operative day four (POD4). All patients underwent cardiac surgery utilizing cardiopulmonary bypass including either coronary artery bypass grafting or valvular procedures. Patients with significant liver or renal dysfunction were excluded from the study. Patients were analyzed according to hematocrit and platelet levels at POD4, as well as by whether they received intra- and/or post-operative transfusions of packed red blood cells. Neurocognitive data is presented as a difference in RBANS standardized score based on sex and age from baseline to POD4 and comparisons analyzed by an unpaired Mann-Whitney U test. 

Results:
There was a significant correlation between patients with hematocrit levels <24% and a decline in neurocognitive function at POD4 (p<0.05). While there was a decrease in platelet levels from pre-op to POD4, there was no significant association with lower platelet levels and neurocognitive decline (p=0.71). All patients experienced a decline in hematocrit levels throughout their hospital stay, but a decline in Hct was associated with a measurable neurocognitive decline by POD4. Those that had a lower Hct on POD4 had consistently lower Hct throughout their stay. Thirty percent of patients received transfusions of packed red blood cells at any time during their hospitalization; 20 percent received a transfusion post-operatively. There was no significant difference between those who received a transfusion at any time during their hospitalization and their neurocognitive function at POD4. However, there was a trend towards lower neurocognitive scores in those who attained a hematocrit greater than 24% by POD4 via a post-operative transfusion. 

Conclusion:
Lower hematocrit levels are correlated with neurocognitive decline following cardiopulmonary bypass. While transfusion overall does not correlate with neurocognitive function, there was a trend towards lower neurocognitive function in those who received a post-operative transfusion. This suggests that their hematocrit was low enough at some point during their hospitalization to negatively affect their neurocognitive function. Therefore, despite goals to limit blood transfusions post-operatively, some patients may require transfusion at either a higher threshold or earlier time point to prevent neurocognitive decline.
 

44.05 Effect of HbA1c on Post-Operative Outcomes After On-Pump CABG

Posted on January 18, 2018

S. Kong1, M. Peltz1, L. C. Huffman1, P. Bajona1, M. A. Wait1, N. Doolabh1, R. Correa1, W. Ring1, M. Jessen1, J. Pruszynski1  1UT Southwestern Medical Center,Department Of Cardiovascular And Thoracic Surgery,Dallas, TX, USA

Introduction: Diabetic patients undergoing major cardiac procedures represent a large, complex group with high risks for complications during the post-operative period. Specifically, an elevated glycated hemoglobin (HbA1c) level is known to be an important predictor and indicator of morbidity and mortality risks for CABG patients. We seek to test the hypothesis that pre-operative HbA1c levels, along with significant covariates, impact post-operative outcomes following on-pump CABG.

Methods: Data were prospectively collected from 669 consecutive patients undergoing on-pump CABG at a single institution between July 2011 and March 2017. HbA1c was collected prior to undergoing surgery. Clinical variables were collected based on the definitions in the STS Adult Cardiac Surgery Database version 2.81. Multivariable logistic regression models were used to assess the effect of HbA1c on post-operative outcomes such as the receipt of post-operative blood products, surgical site infection, and prolonged ventilation. Similarly, a Cox proportional hazards regression model was used to assess the effect of HbA1c on time to discharge while accounting for the competing risk of operative death prior to discharge [operative mortality was 1.9%]. All models controlled for the effect of confounding variables such as demographics, comorbidities and risk factors, medication usage, and surgical characteristics.

Results: No association between HbA1c and the outcomes of post-operative blood products and prolonged ventilation was found in the analysis. A significant relationship between HbA1c and the occurrence of surgical site infection was detected (OR: 1.19; 95% CI: 1.00-1.41; p = 0.045) while controlling for covariates of race, BMI, illicit drug use, pre-operative pneumonia, prior MI, CPB time, and intra-operative blood products. Additionally, a significant association between HbA1c and time to discharge was detected (HR: 1.06; 95% CI: 1.01-1.11; p = 0.017) while controlling for age, smoking history, CVD, PAD, cardiogenic shock, recent heart failure, pre-operative albumin level, intraoperative blood products, surgical status, and post-operative creatinine level [see table].

Conclusion: These data show that increased HbA1c is associated with an increased incidence of a variety of adverse post-operative outcomes even when controlling for known risk factors. Diabetic patients have a variety of physiologic and metabolic derangements, and the exact mechanism behind this observation is not established. The study also does not include the efficacy of perioperative glucose control in these patients. Further investigation is warranted to define the biologic basis of the adverse outcomes that are observed in patients with poor pre-operative glucose control.

44.02 Clinical Characteristics and Surgical Outcomes of Quadricuspid Aortic Valve

Posted on January 18, 2018

K. Yin1,2, Z. Zhang1, L. Dong3, Y. Lin1, C. Wang1  3Zhongshan Hospital Of Fudan University,Department Of Echocardiography,Shanghai, SHANGHAI, China 1Zhongshan Hospital Of Fudan University,Department Of Cardiac Surgery,Shanghai, SHANGHAI, China 2Harvard Chan School Of Public Health,Boston, MA, USA

Introduction:  Quadricuspid aortic valve (QAV) is a rare and poorly understood congenital cardiac anomaly. Controversy remains over its association with aortic dilation, and limited evidence is available regarding the surgical outcomes. This study aims to evaluate the clinical features of QAV and examine the surgical outcomes.

Methods:  From January 2011 to December 2016, 35 consecutive QAV patients (mean age, 50.4 ± 11.9 years; male, 54.3%) were identified by echocardiography and confirmed during surgery (frequency, 0.0057%). All patients had significant aortic insufficiency with severe regurgitation in 21 patients (60%). The mean left ventricular end-diastolic dimension was 5.9 ± 0.7 cm, and the mean ejection fraction was 62% ± 7%. Eight patients (22.9%) had aortic stenosis with mild in 7 and moderate in 1. Ascending aortic diameter was ≥ 4 cm in 7 patients (20%) with mean diameter 4.2 ± 0.2 cm. Three patients (8.6%) had endocarditis preoperatively.

Results: All patients received aortic valve replacement with the median valve size 23 mm (range: 19 to 25 mm). Two patients (5.7%) required ascending aorta replacement, and the other concomitant procedures included mitral repair/replacement in 3 (8.6%) and tricuspid repair in 1 (2.9%). There was no early or late death. The median postoperative ICU and hospital stays were 2 and 7 days, respectively. No myocardial infraction, respiratory failure, renal failure or reoperation for bleeding, occurred postoperatively. Mean follow-up time was 25.1 ± 18.0 months and was complete for 94.3% of patients. One patient developed perivalvular leakage and subvalvular abscess two years after the initial aortic valve replacement and received a reoperative Bentall procedure.

Conclusion: Aortic insufficiency is the predominant hemodynamic abnormally in QAV patients. Compared with those in bicuspid aortic valves, the incidence and extent of aortic dilation seem to be uncommon and less severe in QAV. The short- and mid-term outcomes are satisfactory.

 

44.03 Outcomes of Packed Red Blood Cell and Platelet Transfusion on Aortic Dissection Patients after Surgery

Posted on January 18, 2018

S. Naeem1, G. Baird2, N. Sodha1, F. Sellke1, A. Ehsan1  1The Warren Alpert Medical School,Cardio-Thoracic Surgery,Providence, RHODE ISLAND, USA 2Rhode Island Hospital,Lifespan Bio-Statistics,Providence, RHODE ISLAND, USA

Introduction:

Packed red blood cell (PRBC) and platelet transfusion are associated with morbidity and mortality among adults undergoing cardiac surgery. Our objective was to investigate the clinical effect of transfusion among acute type A aortic dissection (AAD) patients undergoing surgical repair in a large referral hospital.

Methods:

The medical records of 93 AAD patients were retrospectively reviewed and stratified into cohorts by median PRBC and platelet units received; PRBC ≤2 units (N=62) vs PRBC >2 units (N=31); platelets ≤1 unit (N=66) vs platelets >1 unit (N=27). The same dataset was also categorized into four groups; Group 0=no transfusion (N=8); Group 1=platelets only (N=10); Group 2= PRBC and platelets (N=66); Group 3= PRBC only (N=9). Multivariate logistic regression was applied to drive p-values for post-transfusion complications after adjusting for age, gender, history of hypertension and diabetes. Kaplan Meier survival analyses were used to compare the hospital length of stay (LOS) and survival rate at 1-month and 1-year.

Results:

Baseline demographics were similar between all groups. Patients receiving >2U of PRBC had median LOS of 15 vs 8 days, p<0.001. Transfusion of >2 units of PRBC was identified to be an independent risk factor for postoperative infection (OR=5.9, 95% CI: 1.6-21.7, p=0.006). One-month survival rate was 90% in patients receiving ≤2 units PRBC vs 90% in patients receiving >2 units, p=0.811. At 1 year, the survival rate was 89% in patients receiving ≤2 units of PRBC vs 80% in patients receiving >2 units, p=0.644. Patients receiving >1 unit of platelets had a median LOS of 15 vs 10 days, p<0.05. Transfusion of >1 unit of platelets was identified as an independent risk factor for postoperative atrial fibrillation and acute renal failure (OR=2.9, 95% CI: 1.1-8.0, p=0.026; OR=3.7, 95% CI: 1.3-10.6, p=0.014, respectively). One-month survival rate was 89% in patients receiving ≤1 unit of platelets vs 92% in patients receiving >1 unit, p=0.510. At 1 year, the survival rate was 88% in patients receiving ≤1 unit of platelets vs 81% in patients receiving >1 units, p=0.947. On pairwise analysis for the four groups using life table, there was a statistically significant difference in median LOS between group 0 vs 1 (6 vs 8 days, p=0.019) and group 0 vs 2 (6 vs 13 days, p=0.005). Survival at 1-month was 88% for group 0, 100% for group 1, 91% for group 2 and 78% for group 3, (p=0.425). Additionally, survival rate at 1-year was 88% for group 0, 100% for group 1, 84% for group 2 and 78% for group 3, (p=0.507). These results are not statistically significant likely due to the small number of patients.  

Conclusion:

Transfusion of PRBC and platelets above a particular threshold increases the incidence of postoperative complications and hospital LOS among patients undergoing repair of AAD.
 

43.20 Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammoplasty

Posted on January 18, 2018

R. Madada-Nyakauru1, R. Vella-Baldacchino3, A. Bellizzi3, F. Kazzazi2, P. Forouhi4, C. Malata4,5,6  1Cambridge University Hospitals NHS Foundation Trust,Plastic Surgery,Cambridge, Cambridge, United Kingdom 2University Of Cambridge,School Of Clinical Medicine,Cambridge, CAMBRIDGESHIRE, United Kingdom 3University Of Malta,Malta Medical School,Msida, MALTA, Malta 4Addenbrooke’s Hospital,Cambridge Breast Unit,Cambridge, CAMBRIDGESHIRE, United Kingdom 5Addenbrooke’s Hospital,Plastic & Reconstructive Surgery,Cambridge, CAMBRIDGESHIRE, United Kingdom 6Anglia Ruskin University,Postgraduate Medical Institute, Faculty Of Medical Science,Cambridge, CAMBRIDGESHIRE, United Kingdom

Introduction: Therapeutic mammoplasty (TM) is a well-established technique used by oncological and oncoplastic breast surgeons for wide local excision of tumours not amenable to standard breast conserving surgery. It utilises the principles of pedicled breast reduction techniques. In view of the broad experience of plastic surgeons it can easily be incorporated into their practice to treat selected breast cancers.

Methods: A retrospective review of one plastic surgeon’s experience with TM at a tertiary breast cancer referral centre over an 8-year period (2009-2017) was completed. All patients were operated on jointly with a breast surgeon. Clinical records were reviewed to identify relevant clinico-pathological features. Standardised photographs (taken by a professional) were evaluated to assess symmetry through the surgeon’s perspective and objectively with BCCT.coreTM software.

Results: A total of 20 patients who underwent 21 therapeutic mammoplasties were reviewed. Mean age was 50 years (range 37-64) and median bra cup size 36DD. All received adjuvant (postoperative) radiotherapy. Indications for TM included DCIS and invasive breast cancer.  Tumour size ranged from 6 to 87mm (median=35mm). The median resection weight was 220g (range 16-1347g). Most tumours were located in zones 2  (19%) and 7 (14%) of the breast. The main pedicles used for reconstructing the lumpectomy defects/preserving the nipples were the superomedial (58%) and inferior (31%). Five patients had a secondary pedicle to facilitate breast reshaping and maintenance of a satisfactory contour.  Three patients had a Grisotti rotation-advancement flap to recreate a neo-areola.

The pedicle technique used for simultaneous contralateral balancing reduction/lift was the same as for the index breast in 44%. Contralateral breast tissue resection weights ranged from 59 to 1238g (median 416g) and none contained tumour. No revision operations were requested/required and no further balancing surgeries have been performed.

Almost all patients achieved excellent symmetry when reviewed against a standard with the BCCT.coreTM software. Two patients’ cosmetic results were suboptimal due to complications: T-junction wound breakdown (with fat necrosis) and severe radiotherapy shrinkage. Adequate oncological outcomes were achieved as only one patient had positive resection margins (treated by mastectomy and DIEP flap immediate reconstruction). There have been no recurrences to date with a 6-month average follow up. 

Conclusions: TM is effective in achieving good oncological and acceptable cosmetic outcomes in large resections during breast conserving surgery for cancer. The techniques employed are easy to learn and already in the repertoire of all plastic surgeons. They can easily be adopted by plastic surgeons in the treatment of breast cancer who, in close collaboration with breast surgeons, can achieve clear margins with minimal morbidity in selected patients whilst maintaining good cosmetic results.

44.01 Changing Landscape of Cardiac Complications Following Pulmonary Lobectomy: Impact of Approach

Posted on January 18, 2018

Y. Sanaiha1, K. Bailey1, Y. Seo1, E. Aguayo1, V. Dobaria1, A. Iyengar1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:
Cardiovascular complications contribute significantly to the morbidity and resource utilization after pulmonary resections. Rapid growth of healthcare expenditure in the US, a third of which is attributable to surgical procedures, has prompted national initiatives to curtail costs and reduce postoperative complications. Maturation of less-invasive technologies such as video assisted(VA) and robotic assisted(RA) thoracoscopic surgery aim at improving postoperative outcomes by reducing the trauma of surgery, fluid shifts, and hemorrhage. However, the impact of such techniques on the incidence of cardiovascular complications remains unexplored. Since thoracic operations are regarded as high risk for cardiovascular complications, the present work aimed to evaluate changes in cardiovascular complications following open, thoracoscopic and robotic assisted lobectomies in the US. 

Methods:
We performed a retrospective analysis of the Nationwide Inpatient Sample (NIS) for patients having elective open, video assisted and robotic assisted thoracoscopic lobectomy during 2008-2014. Chi-squared analysis was used to compare demographic and hospital characteristics between groups. Logistic regression was performed to determine predictors of in-hospital mortality, postoperative myocardial infarction (POMI) and postoperative pulmonary embolus

Results:
238,647 patients underwent pulmonary lobectomy over the study period(154, 644 open thoracotomy, 72517 VATS, 8486 RATS). Post-operative myocardial infarction rates were similar for VA and RA thoracoscopic groups. In contrast, rates of pulmonary embolism(PE) were higher for patients undergoing RA lobectomy(0.41% vs 0.77%, p<0.0001). Mortality rates for open and robotic groups appear to be uptrending, though this these trends do not reach statistical significance. Thoracoscopic mortality rate is increasing from 0.013% to 0.025%(p=0.025). Utilization of the thoracotomy approach has steadily decreased from 65.5% to 49.8% of all lobectomies(p=0.046). Concomitantly VATS comprises a greater percentage of lobectomies since 2010(from 32.9% to 42.2%).  Regression analysis adjusting for patient co-morbidities and hospital characteristics indicates that for thoracotomy approach is associated with increased odds of POMI, postoperative PE, and mortality(POMI OR 1.3, p=0.008; PE OR 1.8, p<0.001; mortality OR 1.9, p<0.001). Advanced age and Elixhauser score greater than 3 also increase odds of the outcomes of interest. Female gender is the only consistent factor that appears to be protective against POMI, PE, and mortality. 

Conclusion:
While post-operative myocardial infarction and pulmonary embolus are not increase in incidence. The association of these post-operative complications with minimally invasive techniques may reflect a shift in patient selection. Patient and hospital characteristics modeled in the current study do not effectively predict risk factors for these complications beyond surgical technique, age and comorbidity. 
 

43.19 The impact of breast lumpectomy tray utilization on cost-savings

Posted on January 18, 2018

E. B. Malone1, J. R. Baldwin2, J. Richman1, R. B. Lancaster1, H. Krontiras1, C. C. Parker1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA 2UAB Medicine,Perioperative Services,Birmingham, AL, USA

Introduction:
Historically, at a single institution, a 98-instrument head and neck biopsy tray has been used for all breast lumpectomy cases. Observations revealed that many of the instruments included in the head and neck tray were not utilized during these breast cases. Right-sizing instrument trays reduces processing and replacement costs as well as physical strain and turnover times. With the significant number of surgical breast lumpectomies performed annually, a simple tray downsizing could significantly reduce costs and physical strain.

Methods:
Surgical technicians identified instruments needed for a standard breast lumpectomy procedure. Breast surgeons reviewed the list of instruments and made final recommendations. Three of thirteen existing head and neck trays were converted to specific breast lumpectomy trays. The number of breast lumpectomies documented in 2016 was pulled from the institution’s health information system. Instrument quantities were gathered using the institution’s instrument management software. Tray weights were taken on a central sterile scale and instrument processing cost was estimated by a healthcare consultant.

Results:
The new breast lumpectomy trays included 50 instruments compared to the historically-used 98-instrument trays. The reprocessing costs for the instruments decreased from $49.98 to $25.50 resulting in a cost-savings of $24.48 per tray use. With 404 breast lumpectomies performed at the institution in 2016, the annual reprocessing savings totaled $9,890. The weight of the new breast lumpectomy tray was reduced from 27 to 16 pounds. The setup time decreased by 3 minutes, with the head and neck tray requiring 7 minutes for setup and the breast lumpectomy tray requiring 4 minutes.

Conclusion:
Downsizing from a head and neck tray to a specific breast lumpectomy tray demonstrated a reduction in reprocessing cost, tray weight, and set-up time. Fewer instruments resulting in lighter trays allow for safer handling and transport by surgical personnel. In the current healthcare environment, it is important to maximize operating room efficiency and minimize cost. The downsizing of instrument trays accomplishes these goals in a simple way.
 

43.18 Race Predicts Completion of Neoadjuvant Chemotherapy for Breast Cancer

Posted on January 18, 2018

A. T. Knisely2, J. H. Mehaffey1, A. D. Michaels1, D. R. Brenin1, A. T. Schroen1, S. Showalter1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Virginia,School Of Medicine,Charlottesville, VA, USA

Introduction: It is not known what factors affect whether patients complete the prescribed neoadjuvant chemotherapy regimen in breast cancer. Racial and socioeconomic disparities have been demonstrated in breast cancer therapy. We hypothesized that race will be a predictor of completion of prescribed neoadjuvant chemotherapy regimen in patients with breast cancer. 

Methods: Patients diagnosed with breast cancer between 2009 and 2016 treated with neoadjuvant chemotherapy (n=63) at a single institution were reviewed. Patient demographics, socioeconomic status, and tumor characteristics as well as treatment details were abstracted by chart review. Univariate analysis was used to compare variables by completion of neoadjuvant chemotherapy. Unadjusted logistic regression was performed to evaluate the effects of these factors on patient's chances of completing their prescribed chemotherapy regimen.

Results: In our study population, 76.2% (n=48) of the patients completed their prescribed neoadjuvant chemotherapy regimen. On univariate analysis, patients who completed their regimen were significantly more likely to be white (79.2% vs 46.7%, p=0.02). Rates of completion of neoadjuvant chemotherapy were not significantly different among patients with private vs government insurance, positive vs negative nodal status, pathologic complete response, age or tumor size (all p>0.05). Unadjusted logistic regression demonstrated white patients were 7 times more likely to complete neoadjuvant chemotherapy (OR 7.0, p=0.01). Tobacco use significantly reduced the odds of a patient completing neoadjuvant chemotherapy (OR 14.4, p=0.02).

Conclusion: In our patient population of breast cancer patients treated with neoadjuvant chemotherapy, white patients were more likely to complete the prescribed course of neoadjuvant therapy. Future work should evaluate the reason non-white patients are less likely to complete chemotherapy and further assess the racial disparities in breast cancer therapies. 
 

43.16 Does Vitamin D Deficiency Cause Hyperparathyroidism?

Posted on January 18, 2018

L. F. Negrete Cervantes1, F. Cordera1, D. Caba1, E. Moreno1, E. Luque1, M. Muñoz1, E. Cruz1, D. Valdez1, J. Sanchez1, R. Arrangoiz1  1The American British Cowdray Medical Center,Sociedad Quirurgica At Departament Of Surgical Oncology And Head And Neck Tumors,Mexico City, , Mexico

Introduction:
Hyperparathyroidism (HPT) and vitamin D deficiency (VDD) are two associated conditions. In fact, VDD is frequently found in patients with HPT. There are several mechanisms that explain the relationship between HPT and VDD. It is well established that there is an inverse relationship between the levels of parathyroid hormone (PTH) and vitamin D (VD), however, VDD cannot be implicated as the primary cause of HPT (secondary HPT). The aim of our study is to determine if VDD causes HPT.

Methods:
We retrospectively reviewed a prospectively kept database of patients with HPT who were treated surgically from 2013 to 2017 by our surgical group. We obtained and analyzed the levels of VD, PTH, calcium.

Results:
We identified 50 patients (10 men / 40 women) with HPT with a median follow up of seven months (range 1-62). The median age was 56 years (range 29-87). The median preoperative PTH was 96.96 pg/ml (range 26.5-247). The median postoperative PTH at 24 hours and eight weeks after surgery was 33.7 pg/ml (range 1-116.2) and 51.74 pg/ml (range 0-137), respectively. The mean preoperative calcium was 10.15 mg/dL (range 8.8-11.9) and the mean postoperative calcium at 24 hours and eight weeks after surgery was 8.63 mg/dL (range 7.4-11) and 9.2 mg/dL (range 6.9-10.3), respectively. Thirty-five patients (58.3%) had preoperatively VDD before surgery and had subjective exacerbation of their HPT symptoms when the VD was replaced. The median preoperative VD level was 27.5 ng/dL (range 6-112) and at eight weeks after surgery was 25.51 ng/dL (range 17.2-50). This increase in VD levels occurred after the procedure without any VD supplementation. Pathology report showed, as expected, that the HPT was caused by adenomas in almost 89% of the cases and not by VDD.

Conclusion:
In our series, most patients had HPT secondary to adenomas, not 4 gland hyperplasia. VDD improved without VD supplementation after resection of the adenomas. These results may suggest that VDD does not cause HPT.

43.17 Perioperative Considerations for Bloodless Pancreatic Surgery- A Systematic Review

Posted on January 18, 2018

M. Khalili1, W. F. Morano1, L. Marconcini3, M. Sheikh1, M. Styler3, M. Zebrower2, W. Bowne1  1Drexel University College Of Medicine,Division Of Surgical Oncology/Department Of Surgery,Philadelphia, PA, USA 2Drexel University College Of Medicine,Division Of Anesthesia/Perioperative Medicine,Philadelphia, PA, USA 3Drexel University College Of Medicine,Division Of Hematology & Oncology/Department Of Medicine,Philadelphia, PA, USA

Introduction: Bloodless surgery is a multidisciplinary field that seeks to minimize blood
transfusions in surgical patients through a variety of perioperative hemoglobin optimizing
management strategies. Multidisciplinary techniques have been applied to various surgical
subspecialties with favorable outcomes. Bloodless pancreatic surgery (BPS) is a rarely
performed and understudied application of these protocols.

Methods: Literature search was performed on MEDLINE using MeSH terms "bloodless surgery"
or “Jehovah’s witness” and “pancreatectomy” or “pancreaticoduodenectomy,” published
between 2000 and 2017. We reviewed articles focused on BPS and searched references of
relevant articles. We examined implementation of reported preoperative, intraoperative and
postoperative transfusion reduction strategies. We report data regarding categorical variables as
proportions and data regarding quantitative continuous variables as medians with ranges.

Results: Fifteen patients requiring BPS are reported in the literature. We report an additional
three here (N=18). Surgical procedures involved distal pancreatectomy (n=5), radical antegrade
modular pancreaticosplenectomy (n=1), and pancreaticoduodenectomy (n=12). Specifically,
reported strategies fell into three categories: preoperative, intraoperative, and postoperative.
Preoperative strategies include treatment with erythropoietin (n=4), iron (n=4), vitamin B12
(n=1), and vitamin K (n=1). Intraoperative strategies include acute normovolemic hemodilution
(n=8) and cell saver (n=5). Postoperative strategies include treatment with erythropoietin (n=6)
and iron (n=6). Complications for the study cohort include bleeding (n=2), intra-abdominal
abscess (n=1), pancreatic leak (n=2), gastrojejunostomy stricture (n=1) and cardiopulmonary
issues (n=3). No mortalities were reported.

Conclusion: BPS is rarely performed, but feasible. Consultation requires a multidisciplinary
approach. Review of the literature reveals that no single bloodless strategy is used, while
combinations of strategies are employed based upon patient characteristics, multidisciplinary
practice, and surgeon/anesthesiologist preference. With careful patient blood management, BPS
can be performed with good outcomes.

 

43.13 Can Preoperative Thyroglobulin level Predict Thyroid Cancer in Atypia Lesion of Thyroid Nodule?

Posted on January 18, 2018

A. Alhefdhi1,2, T. AlTayyar1, M. Alshehri1,2, S. Alqahtani3, S. ALSobhi1,2, A. Alhefdhi1,2  1King Faisal Specialist Hospital & Research Center,General Surgery/Breast And Endocrine Surgery,Riyadh, RIYADH, Saudi Arabia 2Alfaisal University,General Surgery/Breast And Endocrine Surgery,Riyadh, RIYADH, Saudi Arabia 3Al Majmaah University,Al Majmaah,Al Majmaah, RIYADH, Saudi Arabia

Introduction:  Atypia of Undetermined Significance (AUS) and Follicular Lesion of Undetermined Significance (FLUS) is a heterogeneous group, in which it is difficult to classify as benign, suspicious or malignant. This study aimed to identify any correlation between patients’ demography (age, gender), ultrasound variables, nodule size, preoperative serum thyroglobulin (Tg), and anti-thyroglobulin antibodies (TgAb) levels and the final pathology (benign vs. malignant).

Methods:  A 6-year retrospective review conducted, including all patients diagnosed with AUS or FLUS at a single institution.

Results: Fifty cases were identified with a mean age of 41±12 years. The majorities were females 35(70%). The mean size of the largest thyroid nodule based on the preoperative ultrasound was 38±24mm. Moreover, the median value of the serum TG, and TgAb were 106 (0.4-3385) ug/L, and 16(9-4100) U/ml retrospectively. The mean of the thyroid stimulated hormone (TSH) was 1.83±1.2 mU/L.  The majority of the final pathology on 28(56%) cases demonstrated malignancy, and 22 (44%) cases showed benign pathology. There was no difference between those who have a benign pathology or the malignant pathology in form of age, gender, TG, TgAb, and TSH levels, or the preoperative size of the thyroid nodule. 

Conclusion: Based on our data; in our population; almost half of the patients who found to have AUS or FLUS from the thyroid nodule FNA, found to have a malignancy in the final pathology report.

 

43.14 Thyroidectomy Then and Now – A 50-year Australian Perspective

Posted on January 18, 2018

D. I. Maher1, B. Hii1, M. Yeung1, S. Grodski1,2, J. W. Serpell1,2, J. C. Lee1,2  1Alfred Hospital,Monash University Endocrine Surgery Unit,Melbourne, VIC, Australia 2Monash University,Department Of Surgery,Melbourne, VIC, Australia

Introduction: While modern thyroidectomy originated over 150 years ago in 19th century Europe, the procedure has undergone a major evolution over the last century, and transformed from a procedure associated with high mortality to near zero mortality in modern surgical practice. Nonetheless, surgeons must always strive to improve patient care and reduce mortality and morbidity. Using historical records and analysis of contemporaneously collected data, this study aimed to compare the practice and outcomes of thyroid surgery at a Melbourne tertiary institution during two periods, 50 years apart.

Methods: “The Alfred Hospital Clinical Reports” recorded areas of work being undertaken on the wards and in laboratories of the hospital, including all cases of surgically managed thyroid disease from 1946 – 59 (14-year period). These historical cases were compared to contemporary cases of total thyroidectomy during a 10-year period from 2007 – 16, also at the Alfred Hospital. Data from contemporary cases were recorded in the Monash University Endocrine Surgery Unit (MUESU) database. Cases in the historical and contemporary groups were compared and evaluated for surgery indication and post-operative outcomes including rates of nerve palsy, infection, hemorrhage and mortality.

Results: There were 746 patients in the historical cohort (mean age 53, 87 % female) and 787 patients in the contemporary cohort (mean age 52, 80 % female). Operative complications were studied and recorded in 680 of the historical patients. The most common indication for thyroidectomy in both groups was non-toxic nodular goiter (56 % of historical cases, 35 % of contemporary cases). In the contemporary group, a significantly higher proportion of patients were diagnosed with malignancy of the thyroid compared to the historical group (27 % vs. 8 %; p < 0.001). The historical data documented 36 (5.3 %) cases of recurrent laryngeal nerve palsy (RLNP) following surgery compared to 27 (3.4 %) cases in the contemporary group (p = 0.09). Permanent nerve palsy was noted to be significantly higher in the historical group (4.6 % vs. 0.6 %, p < 0.001), which also had a higher rate of bilateral palsy (8 cases vs. 3 cases p = 0.13). There were no mortalities in the contemporary cohort. The historical data detailed three deaths (0.44 %); two of the deaths were due to thyrotoxic crisis, while the third patient died from post-operative respiratory complications.

Conclusions: This paper uniquely compares the indications and outcomes of thyroid surgery in two cohorts of patients separated by a 50-year period. While non-toxic goitre remains the most common indication for thyroidectomy, an increased number thyroid malignancies were diagnosed in the contemporary group. As expected, morbidity and mortality after thyroidectomy has improved as thyroid surgery has progressed over the past 50 years. Notably, there were fewer cases of death, permanent palsy and bilateral palsy in the contemporary group.

43.15 Ten-Year Ultrasound Follow-ups of Thyroid Surgeries – A Single Institute Experience

Posted on January 18, 2018

T. Zhan2, A. Ali2, C. Hur2,3, C. C. Lubitz1,2  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Massachusetts General Hospital,Institute For Technology Assessment,Boston, MA, USA 3Massachusetts General Hospital,Division Of Gastroenterology,Boston, MA, USA

Introduction:
Incidence of thyroid cancer has been increasing in the United States while survival remains high. With rising cancer detection rate, patients can face high costs of surgeries and numerous ultrasound follow-ups that might be unnecessary. However, there is limited data on surgical pathology diagnosis and follow-ups. We aim to utilize the electronic health records at a tertiary hospital to examine the number of follow-up ultrasounds of thyroid cancer patients. 

Methods:
Ultrasound and surgical pathology reports of patients who had thyroid surgeries, more than one thyroid ultrasound from 2000 to 2016 and at least 10 related visits at this hospital have been extracted from the electronic health records . Patients who had surgery from 2000 to 2005 were included for follow-up analysis. Final diagnoses from surgical pathology reports in free text format were extracted and categorized using regular expression in R version 3.3.2. Thyroid ultrasounds, vital status and reason of hospital visit during 10-year follow up were summarized for patients who had surgery from 2000 to 2005. 

Results:
In our surgical patient cohort from 2000 to 2005, 579(49.8%) patients had surgeries that led to a final benign diagnosis with a mean of 1.14(SD=2.10) ultrasounds during 10-year follow-up.  584(50.2%) patients had a malignant diagnosis with a mean of 5.1(SD = 3.79) follow-up ultrasounds. Among the malignant group, none had following surgeries with malignant diagnoses (Table 1). 94% of the patients had no following surgeries, of which 76.3% survived without radiotherapy or chemotherapy with mean of 5.3(SD=3.62) follow-up ultrasounds. 

Conclusion:

Surgical patients who had malignant pathology diagnosis continued to have high number of ultrasound follow-ups at our hospital while patients with benign diagnosis have less follow-ups or potentially follow up with their local endocrinologists. Most of our surgical cohort survived without having radiotherapy or chemotherapy. It is novel and efficient to use regular expression to extract diagnosis information from free text pathology reports and to provide ultrasound follow-up information comparing surgical patients with benign and malignant diagnosis. 

 

43.11 Hyperthyroidism Symptoms in Children and Adults Seeking Definitive Surgical Treatment

Posted on January 18, 2018

A. A. Asban1, S. Chung1, J. Hur1, B. Lindeman1, C. Balentine1, H. Chen1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:
Graves’ disease is the most common cause of hyperthyroidism in children (84%) and adults (80%), and can present symptoms that could impair development or have substantial long-term implications for quality of life in children. While surgery can offer definitive treatment, anti-thyroid medications and radioactive iodine (RAI) remain the most common therapeutic approaches despite potential side effects and known failure rates. We aimed to determine whether adults and children have different presenting symptoms that may impact therapeutic decisions.

Methods:
We retrospectively reviewed electronic medical records of patients with hyperthyroidism referred for thyroidectomy by one surgeon between January 2016 and April 2017. We divided our cohort into two groups: children (age ≤ 18 years), and adults (age > 18). We compared symptoms between the groups using chi-square for dichotomous variables and Kruskal-Wallis for continuous variables.

Results:

Thirty-eight patients (27 adults & 11 children) were evaluated for hyperthyroidism. Of those, 37 patients (97%) underwent total thyroidectomy and 1 (3%) underwent lobectomy. The mean age of the adult group was 44.3 years and 13.8 years for children. Twenty-nine (76%) were female with no difference in gender among groups. Children with hyperthyroidism were more likely than adults to present with hoarseness (55% vs 15%, p=0.01) and difficulty concentrating (45% vs 7%, p=0.01) (Table 1).

There were no statistically significant differences in the rates of adults and children reporting any other symptoms. A majority of patients in both groups reported palpitations, fatigue, and difficulty swallowing.

Conclusion:
Children with hyperthyroidism were more likely to present with hoarseness and difficulty concentrating than adults. Concentration and communication are critical skills in developing children, and early intervention with definitive therapy may improve such symptoms.

43.12 Makuuchi Incision: The Optimal Approach For Open Adrenalectomy

Posted on January 18, 2018

L. I. Ruffolo1, M. F. Nessen1, C. P. Probst1, D. T. Ruan2, L. O. Schoeniger1, J. Moalem1  1University Of Rochester,Department Of Surgery,Rochester, NY, USA 2Tampa General Hospital,Department Of Surgery,Tampa, FL, USA

Introduction: Surgical excision of the adrenal gland has radically evolved since Charles Mayo first excised a pheochromocytoma in 1927. Although most adrenalectomies are presently undertaken laparoscopically, open adrenalectomy remains the gold standard for large tumors and those concerning for adrenocortical carcinoma (ACC).

Most reports describe the use of midline, subcostal, Mercedes Benz, or thoracoabdominal incisions for open adrenalectomy.  We studied our experience with the Makuuchi incision (MI), a “J” or “L” shaped incision designed to optimize exposure and minimize denervation of the abdominal wall.

 

Methods: We retrospectively reviewed all operations scheduled as “open adrenalectomy” by a single surgeon between 2009 and 2017. Operations performed via non–MI were excluded.  Patient demographics, intraoperative details, and postoperative complications were investigated. We compared surgical site infection (SSI) and hernia rates with published standards. The study was approved by the university IRB.
 

Results: Of 55 open operations identified, 41 were performed via MI (23 right, 17 left, 1 bilateral).  Mean population statistics were as follow: Age 51, BMI 29.7, ASA class 3, tumor diameter 8 cm (range 3.1 to 26 cm), operative time 333 minutes. Thirteen (32%) required multivisceral resection, including, for example, an en-bloc resection of a 20cm pheochromocytoma along with a large hepatic wedge, nephrectomy, and an 8cm segment of vena cava (Fig 1). Six (15%) were for pheochromocytoma, 8 (20%) had ACC, 2 (5%) had oncocytic adrenocortical neoplasm of uncertain malignant potential, and 8 (20%) had non-adrenal pathology.  Forty (98%) had R0 resection on pathology.

Seventeen patients (41%) had prior abdominal surgery.  Twenty-two (51%) were previous or current smokers, and 9 (22%) had hypercortisolemia at surgery. Median length of stay was 6 days, with 80% of patients having LOS<10 days. As of last follow up, (median = 27 months), incisional hernia occurred in 5 (12%). SSI was documented in 3 (7%) patients, two patients with Cushing’s and one immunosuppressed. By comparison, published rates for midline incisions are 9-30%. Postoperative pain was well controlled with PCEA/PCA and POD 1 daily morphine equivalents equating to 0.5 mg of hydromorphone q2h.

Conclusion: The Makuuchi incision affords outstanding exposure of the adrenals and ligamentous attachments of the liver, spleen, and splenic flexure. Incisional hernia and SSI were favorable compared to published rates for midline or subcostal incisions, despite an obese population with a high incidence of hypercortisolism and immunosuppression. Postoperative pain was well controlled.

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